The interest in virtual treatment options has never been stronger than it is right now. Not only are virtual treatment options more convenient in regards to time and location, but they also mitigate the risk of exposure in the era of COVID-19. Unsurprisingly, research and scholarly writing in the areas of telehealth and mobile apps has skyrocketed in the past two years. This has included interest in flexible treatment options for insomnia disorder. There’s no doubt that Cognitive Behavioral Treatment for Insomnia (CBTI) is the gold standard treatment for insomnia disorder (Trauer, et al., 2015). That consensus has led to innovations in the delivery of CBTI. While CBTI was once delivered only face-to-face, its components can now be accessed via telehealth, self-help books, web-based courses, and even standalone mobile apps. The initial research suggests that all of these approaches can be effective (Hasan et al., 2022). This raises the question of whether we even need real live CBTI providers anymore. Have I been innovated out of a job?
A recent network meta-analysis (Hasan et al., 2022) sheds light on this question. The researchers compared CBTI-informed treatments across several delivery options. Methods of delivery ranged from face-to-face individual or group treatment, to telehealth delivery (with and without video) with a live therapist, to the use of automated apps or self-help material. The results demonstrated that participants experienced an improvement in self-reported sleep-related symptoms across all methods. CBTI appears to be a robust treatment that can be delivered over a variety of formats with different levels of professional intervention while still maintaining effectiveness.
Another study (Kuhn et al., 2021) looked specifically at the feasibility and acceptability of the standalone “Insomnia Coach” app for military veterans. This app enables users to track their sleep with a sleep diary, complete assessment measures, and learn about and implement techniques including sleep restriction, stimulus control, and sleep hygiene skills. As a self-directed app, Insomnia Coach can be particularly helpful for patients who have difficulty scheduling weekly or biweekly appointments due to conflicting family, work, or school demands. The results of this pilot study demonstrated that engagement with the Insomnia Coach led to significant improvement in self-reported sleep symptoms. Furthermore, participants indicated that they better understood how to treat insomnia, that their experience using the app was positive and exceeded their expectations, and that they were likely to recommend the app to a friend.
The combined results of these two studies offer hope that we can meet the overwhelming need for treatment of insomnia disorder with automated treatment options. However, a discriminating review of the data paints a more nuanced picture. In the network meta-analysis of virtual treatment options (Hasan et al., 2022), web-based CBTI that included interventions delivered by a therapist offered the best outcomes overall. Interestingly, there was no difference between interventions that included a real provider as opposed to an automated “virtual” therapist. Overall, interventions that lacked video (i.e., telephone-only) were less effective than telehealth delivery with a video component. And while the feasibility and acceptability of the Insomnia Coach was found to be high in a study of military veterans, the sample was a remarkably healthy one. Exclusion criteria was broad and included comorbid sleep diagnoses, changes to medication within the last 2 months, shift work, elevated alcohol intake, and average total sleep time below 5 hours (Kuhn et al, 2021).
In my opinion, looking at the totality of existing data, it may be most useful to consider each CBTI treatment option as meeting a need within a stepped care approach. Self-directed books and apps may be a good starting point for individuals with mild insomnia disorder and who lack complicating comorbidities or other factors. These options may be particularly appropriate for individuals who have difficulty attending appointments consistently due to conflicting demands. As the individual’s presentation becomes increasingly complex, more intensive and tailored approaches may be necessary, such as telephone-based sessions with a provider. At the most resource-intensive end of the spectrum, CBTI with a therapist is likely to be the best choice for patients with more complex needs and presentations. This includes severe insomnia symptoms or the presence of multiple comorbid psychological or physiological conditions. From my perspective, providers’ ability to instill hope and build motivation is particularly important for patients with complex needs. Hope and optimism may be difficult for patients to come by if they have been coping with insomnia a prolonged period of time or when their insomnia is complicated or perpetuated by comorbid conditions that are not fully managed. For example, consider the older veteran who has been living with insomnia for decades, and which is made worse by chronic pain that has not responded to multiple treatments. Motivation may also be difficult to maintain in the face of the more difficult components of CBTI. For example, stimulus control requires patients to get out of bed whenever they are awake for more than a few minutes. This rule can be hard to abide by when it’s dark and cold. Similarly, sleep restriction is often challenging in its initial reliance on sleep deprivation in order to build sleep drive. The skilled provider’s ability to explain the purpose of these interventions, build motivation, and assist with goal setting while gently holding the patient accountable may make the difference between treatment failure and success.
There may never be enough training and financial resources to provide in-person face-to-face CBTI to every patient with insomnia. Having a wide variety of delivery options therefore improves accessibility without completely negating effectiveness. If a patient does not respond to interventions at a lower step of care, they can transition to a higher level for more individualized treatment.
To all my fellow CBTI providers: your services remain extremely valuable!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Carin Lefkowitz, Psy.D., is a clinical psychologist and Senior Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Hasan, F., Tu, Y., Yang, C., Gordon, C., Wu, D., Lee, H., Yuliana, L. Herawati, L., Chen, T., & Chiu, H. (2022). Comparative efficacy of digital cognitive behavioral therapy for insomnia: A systematic review and network meta-analysis. Sleep Medicine Reviews, 61. https://doi.org/10.1016/j.smrv.2021.101567
Kuhn, E., Miller, K., Puran, D., Wielgosz, J., York Williams, S., Owen, J., Jaworski, B., Wu Hallenbeck, H., McCaslin, S., & Taylor, K. (2021). A pilot randomized controlled trial of the Insomnia Coach mobile app to assess its feasibility, acceptability, and potential efficacy. Behavior Therapy. https://doi.org/10.1016/j.beth.2021.11.003
Trauer, J., Qian, M., Doyle, J., Rajaratnam, S., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163(3). https://doi.org/10.7326/M14-2841